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Population Health as Ecosystem Engineering
Session 2, February 12, 2019
Richard Biehl
University of Central Florida
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Richard E. Biehl, Ph.D.
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Objectives (2 minutes)
• Systems Modeling (10 minutes)
• Ecosystem Elements (5 minutes)
• Inputs vs. Components (8 minutes)
• System-of-Systems vs. Ecosystems (5 minutes)
• Population Health (15 minutes)
• Q&A (15 minutes)
Agenda
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• Define requirements for ecological systems modeling of
healthcare
• Categorize ecosystem elements across societal and organismic
system layers
• Differentiate patients as system inputs from populations as integral
ecosystem components
• Contrast traditional system-of-system versus ecological system
strengths and weaknesses
• Propose ecological system management as primary paradigm for
population health
Learning Objectives
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• We are not here to try to master systems
modeling or engineering – the details matter less
than the overall story.
• We are here to adopt a slightly different mindset
about health systems as we begin our HIMSS19
journey together – this story underpins many
topics and sessions this week.
Overarching Objective
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• What different kinds of systems are there?
• Specifically, what are ecological systems?
• What determines the boundaries of a system?
Systems Modeling
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Ecological
System
Function
Ecological System
Function on a grand scale: rivers
moving water, wind moving air,
and biosphere supporting life.
Ecological systems tend to range
from complicated to chaotic.
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Ecological
System
Mechanical
System
Function
Function
Ecological System
Mechanical
System
Sometimes intentionally designed.
Mechanical systems tend to range
from simple to complicated.
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Lake Erie Watershed
(Ecological)
Niagara Falls
(Mechanical)
Niagara Falls (Mechanical)
Function: Increase the linear momentum of
water in the Niagara River by allowing it to fall
in the gravitational field of its ecosystem
Lake Erie Watershed (Ecological)
Function: Collect and consolidate rainfall
and transfer it to the Atlantic Ocean via
the Niagara River.
While not definitional, an
expectation that ecological
systems will exhibit some form
of emergent chaos, and that
mechanical systems won’t, is
helpful when modeling
functional systems.
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Ecological
System
Organismic
System
Mechanical
System
Function
Purpose
Function
Ecological System
Organismic System
Mechanical
System
Evolution
Design
Organismic systems are any distinct
biological individuals that are
capable of varying their behaviors in
multiple ways in response to
information or environmental stimuli.
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Ecological
System
Societal
System
Organismic
System
Mechanical
System
Function
Purpose
Purpose
Function
Ecological System
Societal System
Organismic System
Mechanical
System
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Ecological
System
Societal
System
Organismic
System
Mechanical
System
Function
Purpose
Purpose
Function
Ecological System
Societal System
Organismic System
Mechanical
System
Ecology
Meteorology
Geology
Biology
Mechanics
Electronics
Chemistry
Psychology
Ergonomics
Anthropology
Sociology
Economics
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Lake Erie Watershed
(Ecological)
Erie Utilities
(Societal)
Niagara
Power Station
(Mechanical)
Niagara Falls
(Mechanical)
Niagara Falls (Mechanical)
Function: Increase the linear momentum of
water in the Niagara River by allowing it to fall
in the gravitational field of its ecosystem
Niagara Power Station (Mechanical)
Function: Convert the linear momentum
of water in the Niagara River into
hydroelectric power.
Erie Utilities (Societal)
Purpose: Generate shareholder profits by
exploiting the resources of Niagara Falls to
generate and distribute hydroelectric power.
Lake Erie Watershed (Ecological)
Function: Collect and consolidate rainfall
and transfer it to the Atlantic Ocean via
the Niagara River.
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Universe
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Universe
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System
Universe
While much of our interest in modeling any system is in the internal
structure and interactions of components, we also need to consider the
interaction of the system with the universe within which it resides.
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Environment
System
Universe
The environment includes those non-system aspects of the universe of
interest to the systems engineer, the scope and scale of which will vary
based on the system of interest and the purpose or intent of the modeler.
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Extended System
Environment
System
Universe
The extended system allows aspects of what would otherwise be viewed
as the environment to be treated as part of the system for modeling
purposes, even if only temporarily.
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• The boundary problem puts modelers up against the
environment, both inwardly and outwardly.
• We extend toward the environment – into the ecosystem.
• We collapse toward mechanisms – into the organisms.
• The context provided by the ecology often remains unexamined.
Ecosystems Elements
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Patient
(Organismic Role)
Person
(Organismic)
Patient
(Organismic)
Role = Societal System (of 1 Organismic Component)
Collapses toCollapses to
Much of what we know about a patient is actually limited to
what we see during her or his role as patient.
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Patient (in Nation)
(Extended Organismic)
Extends toExtends to
Nation
(Ecological)
Patient
(Organismic)
Much of what we know about a patient is actually what we know
about the ecological systems in which the patient lives and works.
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Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
We combine organismic systems into societal systems.
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Hospital
(Societal)
Provider
(Organismic)
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Hospital
(Societal)
Provider
(Organismic)
Provider
(Organismic Role)
Hospital
(Societal)
Provider
(Societal Role)
Person
(Organismic)
A societal role can be
unfilled or vacant.
An organismic role can be
unfulfilled or unrealized.
Role Alignment
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Hospital
(Societal)
Provider
(Organismic)
Provider
(Organismic Role)
Hospital
(Societal)
Provider
(Societal Role)
Person
(Organismic)
A societal role can be
unfilled or vacant.
An organismic role can be
unfulfilled or unrealized.
Role Alignment
Provider
(Organismic)
Hospital
(Societal)
Provider
(Societal Role)
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• Inputs represent noise to our systems, sources of variability and
lack of control.
• Components lend themselves to control in some circumstances,
at least more so than inputs.
• The characteristics of inputs is largely driven by the ecological
system from which they are drawn.
Inputs vs. Components
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National Healthcare
(Ecological)
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Hospital
(Societal)
National Healthcare
(Ecological)
As a societal system, a Hospital
will be made up of many layers
of smaller societal subsystems
with many organismic systems.
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Patient
(Organismic Role)
Hospital
(Societal)
Provider
(Organismic)
National Healthcare
(Ecological)
COMPONENT
The people who will fill this role
are mostly beyond the control of
the hospital. It would generally
be misleading to model them as
components of the system.
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Patient
(Organismic Role)
Hospital
(Societal)
Provider
(Organismic)
Population
(Ecological)
National Healthcare
(Ecological)
COMPONENT
Those people will be
drawn from a population
not directly under the
direct control of the
Hospital.
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Patient
(Organismic Role)
Hospital
(Societal)
Provider
(Organismic)
Patient
(Organismic)
Population
(Ecological)
National Healthcare
(Ecological)
COMPONENT
INPUT
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• A system-of-systems combines otherwise separate systems, but
in predictable or standard ways.
• SoS component systems exhibit forms of autonomy.
• Emergence tends to occur at the system level.
• Ecosystems include many other systems.
• Characterized by competition for resources and outcomes.
• Ecosystems behave like unplanned systems of systems.
System-of-Systems vs. Ecosystems
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Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Competition
Two hospitals in the same ecological system will
typically compete with each other, sometimes to
the detriment of both.
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Merged Hospital System
(Societal)
Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Competition
Integration
Two hospitals that merge into
a single societal system
attempt to integrate and
perform as a single entity in
the ecosystem.
Integration might be imperfect, but
the intent is complete integration.
Integration doesn’t preclude local
specialization and focus of
individual subsystems.
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Merged Hospital System
(Societal)
Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Integration
Competition
Hospital Partnership
(Societal)
Hospital
(Societal)
Hospital
(Societal)
National Healthcare
(Ecological)
Cooperation
System of Systems
Defined by emergence
and strange attractors
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• Population members spend more time outside than inside of
healthcare
• Person is much more complicated than Patient
• A person is impacted by many mechanical systems while
participating in many societal systems across many ecosystems
• We lose this complexity when we see only the Patient role.
• Social determinant variables become important to understanding
behaviors, drivers, and outcomes outside of our societal systems
• Population variables emerge from the aggregation of all of this
interaction and complexity
Population Health
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Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
Hospital
(Societal)
Provider
(Organismic)
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Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
Hospital
(Societal)
Provider
(Organismic)
Distance, time,
cost, & stress
Reduced health
outcomes
Avoided or delayed care
No shows & cancellations
Lateness or rescheduling
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Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
Hospital
(Societal)
Provider
(Organismic)
National Healthcare
(Ecological)
Distance, time,
cost, & stress
Reduced health
outcomes
Avoided or delayed care
No shows & cancellations
Lateness or rescheduling
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Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
Hospital
(Societal)
Provider
(Organismic)
National Healthcare
(Ecological)
Extended System
Parking availability
Public transit proximity
Extended System
Residence / work locations
Car ownership / transit options
Caregiver / driver availability
Distance, time,
cost, & stress
Reduced health
outcomes
Avoided or delayed care
No shows & cancellations
Lateness or rescheduling
TRAVEL BURDEN
(Social Determinant of Health)
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Salamon, Julie (2009). Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior,
Money, God, and Diversity on Steroids. New York: Penguin Press. 384 pages. ISBN 9780143115366.
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Salamon, Julie (2009). Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior,
Money, God, and Diversity on Steroids. New York: Penguin Press. 384 pages. ISBN 9780143115366.
Maimonides
Medical Center
(Ecological)
Maimonides
Medical Center
(Societal)
Brooklyn, New York
(Ecological)
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Population
(Ecological)
National Healthcare
(Ecological)
Hospital
(Societal)
Caregiver
(Organismic)
Patient-Caregiver
(Societal)
Patient
(Organismic)
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You are welcome to contact me
with questions at any time:
• Richard E. Biehl, Ph.D.
Online Masters Program, Healthcare Systems Engineering
Industrial Engineering & Management Systems Dept.
College of Engineering & Computer Science
University of Central Florida
• richard.biehl@ucf.edu
• LinkedIN: rbiehl
Questions
Please remember to complete your online session evaluation.Please remember to complete your online session evaluation.
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Appendix
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• Ackoff, Russell L.; & Emery, Fred E. (1972). On purposeful
systems: An interdisciplinary analysis of individual and social
behavior as a system of purposeful events. New Brunswick, New
Jersey. Aldine Transaction.
• Ackoff, Russell L.; & Gharajedaghi, Jamshid (1996). Reflections
on systems and their models. Systems Research, 13(1). p13-23.
• Eriksson, Derek, M. (2004). On the usefulness of the Ackoff-
Gharajedaghi model of system types for the design of business
systems. Systemic Practice and Action Research, 17(2).
• Wheatley, Margaret J. (1999). Leadership and the new science:
Discovering order in a chaotic world. San Francisco: Berrett-
Koehler.
References
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• The theme for this area of my research was originally inspired by
a talk given by Theodore Gordon at a World Future Society
conference in Cambridge, Massachusetts in July 1995.
• The work of Russell Ackoff and Margaret Wheatley have further
inspired and guided my journey.
Acknowledgements
